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Background: Middle manager resistance is often described as a major challenge for upper-level administrators seeking to implement complex innovations such as evidence-based protocols or new skills training. However, factors influencing middle manager support for innovation implementation are currently understudied in the U.S. health care literature.

Purpose: This article examined the factors that influence middle managers' support for and participation in the implementation of work-based learning, a complex innovation adopted by health care organizations to improve the jobs, educational pathways, skills, and/or credentials of their frontline workers.

Methods: We conducted semistructured interviews and focus groups with 92 middle managers in 17 health care organizations. Questions focused on understanding middle managers' support for work-based learning as a complex innovation, facilitators and barriers to the implementation process, and the systems changes needed to support the implementation of this innovation.

Findings: Factors that emerged as influential to middle manager support were similar to those found in broader models of innovation implementation within the health care literature. However, our findings extend previous research by developing an understanding about how middle managers perceived these constructs and by identifying specific strategies for how to influence middle manager support for the innovation implementation process. These findings were generally consistent across different types of health care organizations.

Practice Implications: Study findings suggest that middle manager support was highest when managers felt the innovation fit their workplace needs and priorities and when they had more discretion and control over how it was implemented. Leaders seeking to implement innovations should consider the interplay between middle managers' control and discretion, their narrow focus on the performance of their own departments or units, and the dedication of staff and other resources for empowering their managers to implement these complex innovations.

Emmeline Chuang, PhD, is Postdoctoral Research Scholar, Department of Mental Health Law and Policy, Department of Child and Family Studies, University of South Florida, Tampa. E-mail: echuang@usf.edu.

Jennifer Craft Morgan, PhD, is Associate Director for Research, Institute on Aging, University of North Carolina at Chapel Hill. E-mail: craft@email.unc.edu.

This research was funded by Grant 59245 from the Robert Wood Johnson Foundation to evaluate the "Jobs to Careers: Transforming the Front Lines of Health Care" program. Data collection protocols were approved by the University of North Carolina at Chapel Hill Institutional Review Board.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.